Mechanisms of Ageing and Development, 25 (1984) 189-204 189

Elsevier Scietffic Publishers Ireland Ltd.

CHANGES IN NERVE CELLS OF THE NUCLEUS BASALIS OF MEYNERT IN

ALZHEIMER'S DISEASE AND THEIR RELATIONSHIP TO AGEING AND TO THE
ACCUMULATION OF LIPOFUSCIN PIGMENT

DAVID M.A. MANN*, PETER O. YATES and BORYS MARCYNIUK

Department of Pathology, University of Manchester, Oxford Road, Manchester M13 9PT /Great
Britain)
(Received July 19th, 1983)
(Revision received October 1lth, 1983)

SUMMARY

The number of nerve ceils in the nucleus basalis of Meynert in normally aged persons
is reduced by 30% by 90 years of age and cytoplasmic RNA content and nucleolar
volume b y about 20%. In Alzheimer's disease the changes are greatly exacerbated, with
the cell number being depleted by a further 60% and cytoplasmic RNA content and
nucleolar volume by an extra 35%. Moreover, younger patients with Alzheimer's disease
show a much greater difference from controls of the same age than do older patients;
indeed, by 90 years of age the levels of these changes are similar in Alzheimer's disease
and in old age alone. Lipofuscin content is increased to a similar extent with age in
both Alzheimer's disease and control patients and was associated with loss of cytoplasmic
RNA content and nucleolar volume in both groups. It is suggested that mechanisms which
result in the accumulation of this pigment during life also lower the capability of cells of
the nucleus basalis of Meynert to withstand disease pathogens, leading to a certain degree
of change in old age alone and one which in other persons may be compounded by
secondary factors giving the extreme degeneration of Alzheimer's disease.

Key words: Nucleus basalis of Meynert; Alzheimer's disease; Ageing; Lipofuscin

INTRODUCTION

Only a small part of the total activity of the marker enzyme choline acetyltransferase
(CAT) is thought to be present within cholinergic neurones intrinsic to the neocortex.
The remainder resides within the terminals of ascending fibres [1] whose nerve cell

*To whom all correspondence should be addressed.

0047-6374/84/$03.00 © 1984 ElsevierScientific Publishers Ireland Ltd.

Printed and Published in Ireland
190

bodies are located within the nucleus basalis of Meynert (nbM), the septal nuclei and
other rostral brainstem groups [2,3]. A loss of cerebral cortical CAT activity has been
reported in old people and particularly so in those patients with Alzheimer's disease
[ 4 - 1 2 ] . This may be due to a degeneration or at least a dysfunction of nerve cells within
these other areas.
The intracellular accumulation of lipofuscin pigment with ageing has been associated
in humans with a deterioration in function of nerve cells [13,14]. It is therefore possible
that the large amounts of this material present in nerve cells of nbM [15] may reflect
their viability in later life and in dementia. In this study, therefore, we have measured
the amount of lipofuscin in nerve cells of nbM with age, and in Alzheimer's disease, and
related it to their functional capacity (~e. the ability to form proteins) as assessed by
measurement of nucleolar volume and cytoplasmic RNA content (see ref. 16 for review).

MATERIALS AND METHODS

Brains were obtained at post mortem from 10 moderately to severely demented

patients over the age of 60 years, dying with histologically verified Alzheimer's disease
(Table I); care was taken to exclude from the study any patient in whom there was
evidence of vascular disease and significant brain damage resulting from this. Average
duration of illness, judged from clinical notes as lasting from first examination at hospital
until time of death was 4.8 years (range 11 months to 9 years). Other brains were also
obtained from an age- and sex-matched control group of 10 patients (Table I) and from
a younger series of 10 patients of age range 10-60 years all dying wiihout neurological
or psychiatric illness. In these latter 20 patients there were no significant neuropatho-
logical changes, other than that in certain of the more elderly patients there were minimal
amounts of cerebral softening or Alzheimers-type changes, or both. The immediate cause
of death was similar in all patients, and there were no significant differences in brain
weight or in post-mortem delay time between those with Alzheimer's disease and the
age-matched control group (Table I).
Following weighing, the fresh brains were suspended in 10% neutral formalin and
from the fixed tissue standard blocks, including ones of the nbM, were cut. From these,
paraffin sections cut at 5 /am were stained using conventional neuropathological tech-
niques, including Gros-Bielchowsky (GB) silver staining for neurofibrils. Another 5 sec-
tions of that block containing the most extensive portion of the nbM (~e. that part
between the optic tract and the anterior commissure) were cut at 16/am thickness and
these were stained for RNA using Azure B [17]. In these the total number of nucleo-
lated nerve cells within the nbM was counted and the average number per section, per
patient, calculated. The lipofuscin content, cytoplasmic RNA content and nucleolar
volume, in each of 60 nerve cells of nbM was measured for every patient [13] and from
these individual patient and overall group mean values were determined. Measurements
of frequency of senile plaques and nerve cells containing neurofibrillary tangles were
made on the GB-stained sections in a standard area of middle temporal gyms using the
 191

÷1

.<

o0
0
r.~ ÷1

÷I

Z
o0

÷1

¢",1
-H

~o

r~

+1

0 0%

. 0".
0
4-1
0

[-.. 0
¢',1 v

ee
÷1
0
0 o~
[.... ,.o
r~
o
4-1 E
Z 0 0 0 ~ 0 0 0 0 ~ 0 o~ 0

c-I
÷1

44
192

method of Aherne and Diggle [18] ; details of this technique have been given by us
elsewhere [19].

Histological changes
Controls. The nbM contains clusters of large neurones which contain abundant cyto-
plasmic RNA (Nissl substance) within their cell bodies and a large open nucleus with
finely granular chromatin in which the nucleolus is prominent and strongly basophilic
(Fig. 1). These features make the neurones of nbM clearly distinguishable from other
neurones in the substantia innominata and in adjacent structures. The density of nerve
cells in nbM appeared less in some controls though this may reflect slight variations in
level of sectioning, as much as any actual difference in population.
However, at all ages, there were some neurones which showed an enlarged, vacuolated,
cell body and in which the nucleus was peripherally displaced and the Nissl substance
indistinct (Figs. 1 and 2). In the older patients most neurones of nbM contained large
amounts of lipofuscin pigment and in some of these elderly patients nerve cells with
neurofibrillary tangles were occasionally seen. There was no overall glial cell reaction,
though occasional glial clusters around degenerating neurones were present. No changes
in blood vessels in, or in close proximity to, the nbM were noted.
Alzheimer's disease. In all 10 patients there was a loss of neurones from nbM (Fig. 3),
and many of those still present showed a shrinkage of the cell body, a loss of cytoplasmic

Fig. 1. The nucleus basalis of Meynert in a control patient of 63 years showing nerve cells in large
dusters. Most contain abundant Nissl shustance within their perikarya and the Large open nucleus
shows finely dispersed chromatin and contains a prominently basophilic nueleolus. An enlarged
vacuolated nerve cell is arrowed. Weigert's haematoxylin-eosin, X250.
 193

Fig. 2. Nerve cell (arrowed in Fig. I) shown at higher magnification. Weigert's haematoxylin-eosin,
X400.

Fig. 3. The nucleus basalis of Meynert in a 63-year-old man with Alzheimer's disease. Loss of nerve
cells is apparent and those remaining are atrophied. Weigert's haematoxylin-eosin, X 250.
194

RNA and a small nucleolus within a shrunken nucleus. Vacuolated neurones and others
containing much lipofuscin were again present and the proportion of neurones showing
neurofibriUary degeneration (Fig. 4) was greatly increased. No significant changes in
glial cells or blood vessels in or around nbM were observed.

RESULTS

Mean values of the number of nucleolated nerve cells in nbM per 16/am section,
together with those of their mean nucleolar volume, cytoplasmic RNA and lipofuscin
content, for all 20 control patients are plotted against patient age and shown in
Fig. 5A-D.
The mean number of nerve cells in nbM is significantly reduced with age (Fig. 5A,
Table II) such that by the age of 90 years about 30% of the cell complement has been
lost. Moreover, the cytoplasmic RNA content and nucleolar volume of the remaining
cells are also both significantly decreased with age (Fig. 5C,D; Table Ii) with reductions
of 18% and 21%, respectively, being achieved by 90 years of age. Conversely, the mean
lipofuscin content of these nerve cells increases throughout life (Fig. 5B; Table II). More-
over, in these 20 patients, number of nerve cells, nucleolar volume and cytoplasmic RNA
content all correlated inversely (p < 0.05 in each instance) (Table II) with lipofuscin
content. These findings are consistent with those previously reported by ourselves in
other nerve cell types [13,14]. Although reductions in RNA content with age matched

Fig. 4. The nucleus basalis of Meynert in a 63-year-old man with Alzheimer's disease showing neuro-
fibrillary degeneration of nerve ceils. Palmgren'ssilver stain, X400.
 195

600 A 9o B
÷

÷ 4-
4. 4.
400
4" 4. 4. v [
Z

/
4"

200, 301
._J

Oi

"C A
D
E

<~
40 Lu 4(3 4- 4.
4" 4*
I-. 4.÷ 4"
Z
i,iJ 4. + ' , " + 4 . - * * t ~-
I-- 4"
Z
0
20, ~ 20,
,¢ O
Z
Ix

0|
J
4"0 e'o 2"0 ;o 6o
AGE (years)

Fig. 5. Graph showing the mean number of nerve cells in the nucleus basalis of Meynert (A), their
mean lipofuscin content (B), mean cytoplasmic RNA content (C) and mean nucleolar volume (D) in
20 control patients plotted against patient age.

those in nucleolar volume (Table II), neither of these two features correlated with the
extent of nerve cell loss.
Since none of the 10 control patients aged under 60 years showed senile plaques or
cells bearing neurofibrillary tangles within their neocortex, no correlations linking these
two features to the other histological changes were performed. The frequencies of plaques
and tangles did, however, increase with age (p < 0.001) in the 10 controls aged over
60 years (r = 0.843 and r = 0.861, respectively).
Values of frequency of senile plaques, neurofibrillary tangles in neocortex, mean
number o f cells in nbM and those of nucleolar volume, cytoplasmic RNA and lipofuscin
content are shown for each patient with Alzheimer's disease and each age-matched
control in Table I and III respectively. These individual values are pooled and overall
means for each group of patients derived (Tables I and III). When compared with average
values from the age-matched control group, the frequency of senile plaques and neurofi-
196

TABLE II
PRODUCT MOMENT CORRELATIONS (r) BETWEEN AGE, NUMBER OF NERVE CELLS IN
nbM AND THEIR NUCLEOLAR VOLUME, CYTOPLASMIC RNA AND LIPOFUSCIN CONTENT
FOR ALL 20 CONTROLPATIENTS

Patient Nerve cell RNA Nucleolar Lipofuscin

age (years) number content volume contet~t
(A U]a (t~m s) (FU) b

Patient age (years) --0.613"* --0.463* --0.549* 0.950***

Nerve cell number ---0.613"* 0.289 0.126 -0.510*
RNA content (AU) a -0.463* 0.289 0.691"** -0.453*
Nucleolar volume (#m 3) -0.549* 0.126 0.691"** -0.609**
Lipofuscin content (FU) b 0.950*** -0.510" -0.453* -0.609**

aAU = arbitrary units of light absorption.

bFU = arbitrary units of light fluorescence.
* ,**,***Significant at levelsp < 0.05, <0.01, <0.001, respectively.

brillary tangles in neocortex is significantly greater (p <0.001 for both) in the Alzheimer's
disease patients (Table I). However, the frequency of neurof~rillary tangles in neocortex
correlated significantly with frequency of senile plaques in both Alzheimer (r = 0.759;
p < 0.01) and the age control (r = 0.904;p < 0.001) group. Such a relationship has been
demonstrated previously in Alzheimer's disease in temporal cortex [19,20] and also in
the hippocampus [21]. The number of nerve ceils in nbM is reduced (p < 0.001) in
Alzheimer's disease by about 60% and nucleolar volume and RNA content of those
remaining cells are both decreased by 34% (p < 0.001 in both instances).
The effect of age, in Alzheimer's disease, on these histological and cytological changes
was investigated. The percentage losses of nerve cells from nbM and reductions in RNA
content and nucleolar volume of those remaining were calculated for each patient with
Alzheimer's disease, by comparing actual patient values of these features with those
expected for patient age alone, as derived from the linear regressions shown in Fig. 5.
The frequency of senile plaques and neurofibrillary tangles in neocortex both correlated
inversely with patient age [r = --0.572 plaques, r = --0.597 tangles, p < 0.05 for both
(Fig. 6)]. Percentage loss of nerve cells in Alzheimer's disease similarly correlated in-
versely with patient age (r = ---0.613, p < 0.05), as did percentage reductions in RNA
content (r = ---0.831, p < 0.01) and nucleolar volume (r = --0.792, p < 0.01) (as shown
in Fig. 7). In other words, younger patients with Alzheimer's disease show a much greater
difference from controls of the same age than do older patients. Indeed, after about
90 years of age all five features show similar levels of change in both Alzheimer's disease
and in old age alone. Percentage loss of nerve cells from nbM and percentage reductions
in RNA content and nucleolar volume of remaining ceils were correlated with frequency
of senile plaques and neurofibrillary tangles within neocortex (Table IV). Percentage
loss of nerve cells from nbM correlated only weakly with plaque and tangle frequency,
though these correlations with percentage reductions in nucleolar volume and RNA
content in remaining cells were highly significant (Table IV).
 197

r.~ +1 .~ 44 .44 +1 +1 +1 +1 -+4 +i 4-t

'~il- t ' q t'-.- " , ~ 0 oo ,~1- QO o o ~','~ t'.-

E~
0

+1 +l +1 +I +1 +t +1 +1 +I +L +1

+l +l +1 +! +1 +t +1 +L +1 +1 +1

+L

=g

+i +1 +t +1 +i +t +[ +t +1 +1 +1
0 ,

~m

o
o
Z< 0
v

+I +I ~ ~ +I ~ +I +I +I

E
-i
÷t o

z~ 0

C~

+I

r~
Ji li .~

[-. JD
198

A B
+
+ E
E
"~ 60,

÷ ÷
u,l
40, ~" 40,
"~ >-
O n-

.J

++ Ilc

Lu
(/) 20, ÷4" + ~r~ 20,

0,

r~ 8o 1~o r~ ~o 1~o
AGE (years)

Fig. 6. Graph of frequency of senile plaques (A) and neurofibrillary tangles (B) in neocortex in 10
patients with Alzheimer's disease plotted against patient age. Also shown as dotted line is the regres-
sion line for these changes in the 10 age-matched control patients derived from data in Table I.

Although the average amount of lipofuscin pigment within remaining cells of nbM
increases with age, within the group of patients with Alzheimer's disease (r = 0.920,
p < 0.001 ; Fig. 7B) this is at the same rate as in the control patients (Fig. 5B). These
findings are similar to those we have reported elsewhere for other nerve cell types [22] ;
Le. the average amount of this waste pigment within nerve cells of nbM in Alzheimer's
disease is no different, at any age, from that present within control patients (Table III).
The relationship in individual patients between the amount of lipofuscin within
individual nerve cells of nbM and the volume of their nucleolus and thek RNA content,
was also investigated by regression analysis for one of the younger control patients, an
older patient with Alzheimer's disease (Alzheimer patient 7) and an age-matched older
control (control patient 7). These three were chosen to be representative of their respec-
tive group as their ages and values for nerve cell number, nucleolar volume, RNA and
lipofuscin contents, all most closely matched their respective mean group values.
In both the younger and the older control the amount of lipofuscin within neurones
of nbM correlated inversely 09 < 0.001 in each instance) with both cytoplasmic RNA
content (r = ---0.899 young, r = --0.922 older) and nucleolar volume (r = --0.884 young,
r = ---0.864 older). Moreover, covariant analysis showed that the regression lines for the
relationships between lipofuscin and cytoplasmic RNA content, and between lipofusein
content and nucleolar volume, were similar in both:
 199

80, A 70, B +
÷

÷ ÷ +
o3
o3
g¢ 6o, 60,
t.u Z
<~ z
O
¢.J
Z *.u
t.u Z z
¢ 40 50,

i ~ ~ ÷
20
40,

'~C
60 ' 60

~ ,o + . i > ~ ,o

~,z,= 20, g=~z

~ 20 # ..~
~ ~ +
== . . . . . . -~- --

0 0

go' 8-o ¢o ~o ~o 5"0 8"0 ¢o 8"0 ~'o

AGE (years)
Fig. 7. Graphs of percentage reduction in number of nerve cells in nucleus basalis of Meynert (A),
lipofuscin content (B), and reductions in cytoplasmic RNA content (C) and nucleolar volume (D) in
10 patients with Alzheirner's disease plotted against patient age. Also shown as dotted lines are the
regression lines for these changes in all 20 control patients as derived from data in Fig. 5.

(Young) RNA (Y) X lipofuscin (X): Y = 46.3 -- 0.25X

(Older) RNA (Y) X lipofuscin (X): Y = 45.8 - - 0 . 2 3 X
(Young) Nucleolar volume ( Y ) X lipofuscin (X): Y = 46.0 - 0.27X
(Older) Nucleolar volume (Y) X lipofuscin (X): Y = 46.6 -- 0.25X

In the patient with Alzheimer's disease lipofuscin content (X) again correlated in-
versely (p < 0.001) with both cytoplasmic RNA content (Y = 39.2 - 0.27X; r = --0.801)
and nucleolar volume (Y = 36.2 - 0.23X; r = --0.707). Although both nucleolar volume
and RNA content were decreased overall in the Alzheimer's disease patient (when com-
pared with the age-matched control) by 35%, it is notable that both these features were
reduced by over 45% in nerve cells with high (>80 units) levels of lipofuscin, but only
by 20% in cells with low (<20) levels.
200

TABLE IV
PRODUCT MOMENT CORRELATIONS (r) BETWEEN PERCENTAGE LOSS IN NUMBER OF
NERVE CELLS IN nbM AND PERCENTAGE REDUCTIONS IN NUCLEOLAR VOLUME AND
CYTOPLASMIC RNA CONTENT WITH FREQUENCIES OF SENILE PLAQUES AND NEURO-
FIBRILLARY TANGLES IN NEOCORTEX, FOR THE 10 PATIENTS WITH ALZHEIMER'S
DISEASE

Neocortex

Senile plaques (n/mm 2j Neurofibrillary tangles (n/mm ~)

Nucleus bamlis
Nerve cell number 0.543* 0.662*
RNA content (A UJa 0.687* 0.831"*
Nucleolar volume t~m 3) 0.813"* 0.872***

aAU = arbitrary units of light absorption.

*,**,***Significant at levelsp < 0.05, <0.01, < 0.00 I, respectively.

DISCUSSION

In this study we have shown that both the number and the function of nerve cells of
the nbM are progressively decreased with ageing such that by the 10th decade about 30%
of the original complement is lost and the capacity to form proteins for physiological
action is also reduced in those nerve cells that are still present. This pattern of damage
is, however, greatly exacerbated in Alzheimer's disease where nerve cell numbers are on
average depleted by a further 60% (making an overall cell loss of 70% when compared
with young adults); the capacity for protein production is decreased by an extra 35%
(making 40% difference overall). Other degenerative features of old age such as neuro-
fibrillary tangle formation are more common in Alzheimer's disease. These findings
confirm and enlarge those of Whitehouse et aL [23,24], Perry et aL [25] and Candy
et aL [26], who reported a loss of nerve cells from nbM in patients with "sporadic"
Alzheimer's disease [23,25,26] and also in a single patient with the familial form of this
illness [24]. The correlations between the cell loss and reductions in indices of perikaryal
function within the nbM and the frequency of senile plaques within neocortex suggest
that at least some of the degenerating neurites within evolving "plaques may be branches
of axons from nbM. Indeed the demonstration of acetylcholinesterase activity in such
neurites [27,28] would substantiate this. Correlations between changes in nbM and
neurofibrillary tangle frequency may simply reflect parallel degeneration within cortex
and subcortex and need not necessarily imply any close causal relationship.
The reductions in markers of cholinergic activity in the cerebral cortex in old age and
in Alzheimer's disease [4-12] are probably due to the loss of nerve cells from nbM
combined with the decrease in protein synthesis capacity in those that survive; the
failure to produce CAT and synthesize acetylcholine may be only one aspect of this
metabolic change. Damage to cholinergic neurones in the septal ttuclei [29] is, in a
 201

similar way, probably responsible for loss of CAT activity within the hippocampus
[5,7,81.
Furthermore, our finding of a lessening in the severity of changes in nbM in
Alzheimer's disease, with advancing age, in conjunction with the fact that the changes
we have shown become more severe with ageing alone reconciles other studies [23-26]
in which, when compared with age-matched controls, younger patients with Alzheimer's
disease lose over 75% of nerve cells from nbM [23], yet in older patients the loss is only
33% [25,26]. Such findings also explain why losses of CAT activity are usually much
more pronounced in younger persons with Alzheimer's disease [8,9,11,12] and also why
either only slight or no significant losses of CAT activity can occur in some of the very
old people with Alzheimer's disease when compared to age-matched controls, at least
as far as areas of frontal cortex are concerned [11,12]. Since no correlation was found
between duration of illness and patient age it may be that the more pronounced changes
in the younger person with Alzheimer's disease actually reflect a more severe process of
disease. Unfortunately we were unable to confirm that the younger patients were more
mentally impaired by relating the severity of the pathological changes to the degree of
dementia because, even though most patients had been formally assessed (usually on
several occasions) during the course of their illness, there was no common point in time
before death at which such ratings could be reliably compared.
Damage to neurotransmitter systems in Alzheimer's disease is not, however, restricted
to that based on acetylcholine. Degeneration and loss of the melanin-containing nerve
cells of the locus coeruleus, which forms the main part of the brain's noradrenergic
system, have also been well established [30-33]. Other reports [34,35] indicate involve-
ment of serotonin pathways based on the raphe nuclei of the brain stem and mid brain.
As is seen with the cholinergic system, damage to the noradrenergic and serotonin
systems is also more pronounced in the younger person with Alzheirner's disease, in old
people with dementia the difference from the changes already observed without dementia
is again much less marked [35a]. Moreover, the extent of degeneration of the noradren-
ergic and serotonin systems with a group of patients with Alzheimer's disease broadly
parallels that of the cholinergic system [35a].
These three nerve cell types give rise to ascending pathways which, although projecting
to different regions of the cerebral cortex, all form part of a larger group that has been
collectively termed "the isodendritic core" [36] and which extends from the basal fore-
brain to the spinal cord and subsumes what corresponds to the reticular formation.
A feature of nerve cells of this area is the particularly large quantities of lipoprotein
pigments that they accumulate by middle age and beyond: :q~ofuscin in cells of nbM
and raphe nuclei, neuromelanin in those of the locus coeruleus. An increasing amount
of pigment within these cell types has been shown both here and elsewhere [ 13,14,37]
to be associated with reductions in the quantity of cytoplasmic RNA and the volume of
the nucleolus. Such findings imply a progressive lowering of protein synthetic capacity
as pigment is accumulated. Thus these heavily pigmented nerve cells of the isodendritic
core would, as time passes, not only be less able to respond quickly in terms of activity
202

or stress, but would also be less capable of withstanding the effects of chance exposure
to pathogens which might easily lead to their metabolic collapse and the progressive
fall off in number that occurs in later life (see here and ref. 38). By this argument, the
changes seen in these cell types in Alzheimer's disease would represent a worsening of
this ageing process, precipitated by a pathogenic insult of sufficient severity as to result
in the rapid loss of cells within the isodendritic core. Since these nerve cell types are
"fitter" in younger persons (Figs. 5 and 3C), so a "higher level" of exposure to pathogen
would be required to precipitate Alzheimer's syndrome in such patients and consequently
greater degrees of pathological damage and neurological disturbance would be expected.
With ageing, these nerve cell types become weaker, so progressively lower levels of
exposure to pathogen would be able to precipitate the illness and, in turn, the extent of
the pathological changes and that of the dementia would become less severe. The changes
we have reported here and the observation that the incidence of Alzheimer's disease
rises with age [39], would all be consistent with such a mechanism of disease.
We suggest, therefore, that the subcortical changes of Alzheirner's disease stems from
an aggravation by secondary factors of basic alterations associated with pigment accumu-
lation within neurones of nbM, locus coeruleus, raphe nuclei (and perhaps also other
groups of the isodendritic core) which occur as part of their "normal process of ageing".
Any one of a wide spectrum of compounding factors (and not necessarily the same one
in every instance) such as the action of viruses (~e. Herpes simplex [40-43] ) or toxins
such as aluminium [44-46] or perhaps deficiencies in the blood-brain barrier [47,48]
which allow these agents to gain access to the central nervous system, might therefore
be the change that tips the balance between acquisition and non-acquisition of disease.
This could explain why attempts to relate a single specific factor to the incidence of the
disorder have so far been unsuccessful.

ACKNOWLEDGEMENT

We thank Mrs P. Bellinger for the preparation of the manuscript.

REFERENCES

1 M.W. Johnston, M. McKinney and J.T. Coyle, Neocortical cholinergic innervation: a description
of extrinsic and intrinsic components in the rat. Exp. Brain Res., 3 (1981) 159-172.
2 I. Divac, Magnocellular nuclei of the basal forebrain project to neocortex, brainstem and olfactory
bulb. Review of some functional correlates. Brain Res,, 93 (1975) 385-398.
3 P.C. Emson and O, LindvaU, Distribution of putative neurotransmitters in the neocortex. Neuro-
science, 4 (1979) 1-30.
4 P.L. McGeerand E.G. MeGeer,Enzymes associated with the metabolism of eatecholamines, acetyl-
choline and GABA in human controls and patients with Parkinson's disease and Huntington's
chorea. J. Neurochem., 26 (1976) 65-76.
5 E.K. Perry, P.H. Gibson, G. Blessed, R.H. Perry and B.E. Tomlinson, Neurotranmaitter enzyme
abnormalities in senile dementia. 9'. Neurol. ScL 34 (1977) 247-265.
6 P. White, C.R. Hiley, M.J. Goodhardt, L.H. Carrasco, J.P. Keet I.E.I. Williams and D.M. Bowen,
Neocortical cholinergic neurones in elderly people. Lancet, i (1977) 668-670.
 203

7 P. Davies, Loss of choline acetyl transferase activity in normal aging and in senile dementia. Adv.
Exp. Med. Biol., 113 (1978) 251-256.
8 P. Davies, Neurotransmitter-related enzymes in senile dementia of the Alzheimer type. Brain
Res., 1 71 (1979) 319-327.
9 D.M. Bowen, P. White, J.A. Spillane, M.J. Goodhardt, G. Curzon, P. Iwangoff, W. Meier-Ruge
and A.N. Davison, Accelerated ageing or selective neuronal loss as an important cause of dementia.
Lancet, i (1979) 11-14.
10 E.G.S. Spokes, An analysis of factors influencing measurements of dopamine, noradrenaline,
glutamate decarboxyiase and choline acetylase in human post mortem brain tissue. Brain, 102
(1979) 333-346.
11 M.N. Rossor, L.L. Iversen, A.J. Johnson, C. Mountjoy and M. Roth, Cholinergic deficit in frontal
cerebral cortex in Alzheimer's disease is age dependent. Lancet, ii (1981) 1422.
12 G.K. Wilcock, M.M. Esiri, D.M. Bowen and C.C.T. Smith, Alzheimer's disease. Correlation of
cortical choline acetyl transferase activity with the severity of dementia and histological abnor-
malities. J. Neurol. Sci., 57 (1982) 4 0 7 - 4 1 7 .
13 D.M.A. Mann and P.O. Yates, Lipofuscin pigments and their relationship to ageing in the human
nervous system - I. The lipofuscin content of nerve cells. Brain, 97 (1974) 4 8 1 - 4 8 8 .
14 D.M.A. Mann, P.O. Yates and J.E. Stamp, Relationship of lipofu~in pigment to ageing in the
human nervous system. J. Neurol. Sci., 35 (1978) 8 3 - 9 3 .
15 P. Averback, Lesions in the nucleus ansae peduncularis in neuropsychiatric disease. Arch. NeuroL,
38 (1981) 230-235.
16 D.M.A. Mann, Nerve cell protein metabolism and neurological disease. Neuropathol. Appl. Neuro-
biol., 8 (1982) 161-176.
17 J.R. Shea, A method for the in situ estimation of absolute amount of ribonucleic acid using
Azure B. J. Histochem. Cytochem., 18 (1970)128--135.
18 W.A. Aherne and P.J. Diggle, The estimation of neuronal population density by a robust distance
method. J. Microsc., 114 (1978) 285-293.
19 D.M.A. Mann, D. Neary, P.O. Yates, J. Lincoln, J.S. Snowden and P. Stanworth, Neurofibrillary
pathology and protein synthetic capability of nerve cells in Alzheimer's disease. Neuropathol.
Appl. Neurobiol., 7 (1981) 37-47.
20 G.K. Wilcock and M.M. Esiri, Plaques, tangles and dementia. A quantitative study. J. Neurol. Sci.,
56 (1982) 343-356.
21 P.M. Farmer, A. Peck and R.D. Terry, Correlation among numbers of neuritic plaques and neuro-
firbillary tangles and severity of senile dementia. J. Neuropathol. Exp. NeuroL, 35 (1976) 367.
22 D.M.A. Mann and K.G.A. Sinclair, The quantitative assessment of lipofuscin pigment, cytoplasmic
RNA and nucleolar volume in senile dementia. Neuropathol. Appl. Neurobiol., 4 (1978) 129-135.
23 P.J. Whitehouse, D.L. Price, R.G. Struble, A.W. Clarke, J.T. Coyle and M,R. De Long, Alzheimer's
disease and senile dementia. Loss of neurones in the basal forebrain. Science, 215 (1982) 1 2 3 7 -
1239.
24 P.J. Whitehouse, D.L Price, A.W. Clarke, J.T. Coyle and M.R. De Long, Alzheimer's disease:
evidence for selective loss of cholinergic neurones in the nucleus basalis. Ann. NeuroL, 10 (1981)
122-126.
25 R.H. Perry, J.M. Candy, E.K. Perry, D. Irving, G. Blessed, A.F. Fairburn and B.E. Tomlinson,
Extensive loss of cholineacetyltransferase activity is not reflected by neuronal loss in the nucleus
of Meynert in Alzheimer's disease. Neurosci Lett., 33 (1982) 311-315.
26 J.M. Candy, R.H. Perry, E.K. Perry, D. Irving, G. Blessed, A.F. Fairburn and E.B. Tomlinson,
Pathological changes in the nucleus of Meynert in Alzheimer's and Parkinson's disease. J. Neurol.
Sci., 59 (1983) 277-289.
27 R.H. Perry, G. Blessed, E.K. Perry and B.E. Tomlinson, Histochemical observations on the cholin-
esterase activities in the brains of elderly normal and demented (Alzheimer type) patients. Age
Ageing, 9 (1980) 9 - 1 6 .
28 R.G. Struble, L.C. Cork, P.J. Whitehouse and D.L. Price, Cholinergic innervation in neuritic
plaques. Science, 216 (1982) 413-415.
29 I. Nakano and A. Hirano, Loss of large neurones of the medial septal nucleus in an autopsy case
of Alzheimer's disease. J. Neuropathol. Exp. Neurol., 41 (1982) 341.
204

30 D.M.A. Mann, J. Lincoln, P.O. Yates, J.E. Stamp and S. Toper, Changes in monoamine containing
neurones of the human CNS in senile dementia. Br. J. Psychiatry, 136 (1980) 533-541.
31 B.E. Tomlinson, D. Irving and G. Blessed, Cell loss in the locus caeruleus in senile dementia of
Alzheimer type. J. Neurol. Sci., 49 (1981) 419-428.
32 D.M.A. Mann, P.O. Yates and J. Hawkes, The noradrenergic system in Alzheimer's and multi-
infarct dementias. J. Neurol. Neurosurg, Psychiatry, 45 (1982) 113-119.
33 W. Bondareff, C.Q. Mountjoy and M. Roth, Loss of neurones of adrenergic projection to cerebral
cortex (nucleus locus coeruleus) in senile dementia. Neurology, 32 (1982) 164-169.
34 J.S. Benton, D.M. Bowen, S.J. Allen, E.A. Haan, A.N. Davison, D. Neary, R.P. Murphy and J.S.
Snowden, Alzheimer's disease as a disorder of isodendritic core. Lancet, i (1982) 456.
35 D.M.A. Mann and P.O. Yates, Serotonin nerve cells in Alzheirner's disease. J. Neurol. Neurosurg.
Psychiatry, 46 (1983) 96.
35 (a) D.M.A. Mann, P.O. Yates and B. Marcyniuk, Presenile Alzheimer's disease, senile dementia of
Alzheimer type and Down's syndrome of middle age all form an age-related continuum of patho-
logical changes. Neuropathoi. Appl. Neurobiol., (in press).
36 E. Ramon-Molllner and WJ.H. Nauta, The isodendritic core of the brain stem. J. Comp. Neurol.,
126 (1966) 311-336.
37 D.M.A. Mann, P.O. Yates and C.M. Barton, Melanin and RNA in cells of the human substantia
nigra. J. Neuropathol. Exp. Neurol, 36 (1977) 379-383.
38 D.M.A. Mann, P.O. Yates and J. Hawkes, The pathology of the human locus coeruleus Clin.
Neuropathol., 2 (1983) 1-7.
39 D.W.K. Kay, P. B~amish and M. Roth, Old age and mental disorders in Newcastle-upon-Tyne -
part 1 a study of prevalence. Br. J. Psychiatry, 110 (1964) 146-158.
40 L.W. Sequiera, L.H. Carrasco, A. Curry, L.C. Jennlngs, M.A. Lord and R.N.P. Sutton, Detection
of Herpes simplex viral genome in brain tissue. Lancet, ii (1979) 609-612.
41 D.M.A. Mann, P.O. Yates, J.S. Davies and 5. Hawkes, Viruses, Parkinsonism and Alzheimer's
disease. J. Neurol. Neurosurg. Psychiatry, 44 (1981) 651.
42 M.M. Esixi, Viruses and Alzheimer's disease. J. Neurol. Neurosurg. Psychiatry, 43 (1982) 759.
43 D.M.A. Mann, A.-M. Tinkler and P.O. Yates, Neurological disease and Herpes simplex virus: an
immunohistochemical study. Acta Areuropathol., 60 (1983) 24-28.
44 D.R. Crapper, S.S. Krishnan and S. Quittkat, Aluminium, neurofibriUary degeneration and
Alzheimer's disease. Brain, 99 (1976) 67-80.
45 D.R. Crapper, S. Quittkat, S.S. Krishnan, A.J. Dalton and U. De Boni, Intranuclear aluminium
content of Alzheimer's disease, dialysis encephalopathy and experimental aluminium encephalo-
pathy. A cta Neuropathol., 50 (1980) 19-24.
46 D.P. Perl~ Alzheimer's disease: X-ray spectrometric evidence of aluminium accumulation in neuro-
fibrillary tangle bearing neurones. Science, 208 (1980)297-299.
47 D.M.A. Mann, J.S. Davies, P.O. Yates and J. Hawkes, Immunohistochemical staining of senile
plaques. Neuropathol. Appl. Neurobiol., 8 (1982) 55-61.
48 H.M. Wisniewski and P.B. Kozlowski, Evidence for blood-brain barrier changes in senile dementia
of the Alzheimer type. Ann. N. Y. Acad. ScL, 396 (1982) 119-129.